Health inspection·July 31, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to conduct comprehensive assessment and implement wound care management for one (R1) of three residents reviewed for skin alteration. This deficiency resulted in R1's abrasion on the left great toe deteriorated to necrosis, gangrene, infection of left foot, and needs amputation. Findings include:R1 is an [AGE] year-old, male, admitted in the facility on 07/03/25 with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Type 2 Diabetes Mellitus without Complications; Pain in Right Foot; Pain in Left Foot; and Multiple Subsegmental Thrombotic Pulmonary Emboli without Acute Cor Pulmonale. MDS (Minimum Data Set) dated 07/10/25 recorded R1's BIMS (Brief Interview for Mental Status) score is 0, which means severe cognitive impairment.R1's progress notes documented:07/03/25: received R1 in stable condition. The left great toe had a D/I (debridement and irrigation) done, has order for Silvadene 1% topical cream with dressing daily, and to follow up with Podiatry.07/04/25 - Skin/Wound note: abrasion noted to the left great toe with some discoloration. R1's POS (Physician Order Sheet) dated 07/03/25 recorded: Silver Sulfadiazine external cream 1% (Silver Sulfadiazine) apply to left great toe, nail area topically one time a day for dermatology.Wound assessment detail report dated 07/04/25 documented R1's Left toe as abrasion present upon admission, measuring 4 cm (centimeters) x 2 cm x 0.10 cm with light amount of blood exudate.On 07/28/25 at 11:28AM, V5 (Wound Care Coordinator) was asked regarding R1's abrasion on the left great toe. V5 stated, When he (R1) was admitted , he was assessed to have abrasion on the left great toe. Initially he came from the hospital with orders of Silvadene cream and we were applying it. Then the podiatrist (V10) saw him two to three days prior to discharge and changed the order to betadine and dry dressing. R1's POS documented the following:07/09/25: Cleanse left great toe with normal saline, apply betadine-soaked gauze and a dry dressing, every 8 hours as needed for if soiled or dislodged.07/09/25: Cleanse left great toe with normal saline, apply betadine-soaked gauze and a dry dressing, every day shift every Tue, Thu, Sat to promote skin healing. Medical Practitioner note dated 07/12/25, authored by V10 (Podiatrist) recorded the following:Date of service 07/09/25Physical Exam: Integument - necrosis of left hallux noted. R1 was seen by V10 on 07/09/25, noted necrosis of the left hallux. However, wound assessment details reports dated 07/11/25 still documented his (R1) left toe as abrasion, measuring 4 cm x 2 cm x 0.10 cm, with light amount of bloody exudate.On 07/28/25 at 12:05PM, V6 (Licensed Practical Nurse/Treatment Nurse) was asked regarding R1's wound on the left great toe. V6 verbalized, Upon admission, he had an abrasion to his left great toe with some discoloration. He had admitting orders from hospital for Silvadene. When I did the assessment, he had the abrasion to his left toe with discoloration. The wound was bluish dark in color, had some discharges under nail, the nail was still there, there was pain but no swelling. R1's medical practitioner progress note dated 07/10/25 recorded:Plan: Cellulitis and necrosis of left great toe; wound care on consult with wound care orders, in ongoing Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146053 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)